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A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact isolation. This is because MRSA is primarily spread through direct physical contact with the infected individual or contaminated surfaces. By implementing contact precautions, the nurse can prevent the spread of MRSA to other patients and healthcare workers. Droplet precautions (choice A) are used for diseases spread through large respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small respiratory droplets that remain suspended in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. Therefore, the most appropriate precaution for a client with MRSA at 36 weeks gestation is contact isolation.
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A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. Hemolytic disease in newborns is caused by Rh incompatibility, where the mother is Rh negative and the father is Rh positive. This leads to the mother developing antibodies against the Rh-positive fetal red blood cells, resulting in hemolysis in the fetus. The other choices are incorrect because Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, not when both parents are Rh positive (choice C) or both are Rh negative (choice D). This educational program should emphasize the importance of Rh factor compatibility in preventing hemolytic disease in newborns.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration 200 mg/ 24 hr
- B. Creatinine 0.8 mg/ dL
- C. Hemoglobin 14.8 g/ dL
- D. Platelet Count 60.000/ mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet Count 60,000/mm3. In preeclampsia, low platelet count can indicate thrombocytopenia, a serious complication that can lead to bleeding. This finding requires immediate attention to prevent severe complications like hemorrhage or organ damage.
A: Urine protein concentration within normal range for preeclampsia.
B: Creatinine within normal range, not a priority in this scenario.
C: Hemoglobin within normal range, not a priority in this scenario.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
- A. Varicella
- B. Human papillomavirus
- C. Diphtheria - acellular pertussis
- D. Inactivated influenza
Correct Answer: C,D
Rationale: The correct vaccinations for a pregnant client at 30 weeks gestation are C: Diphtheria-acellular pertussis (Tdap) and D: Inactivated influenza. Tdap is recommended during every pregnancy to protect the newborn from whooping cough, and influenza vaccine is safe and crucial to prevent flu-related complications. Varicella (A) and Human papillomavirus (B) vaccines are contraindicated during pregnancy due to potential risks to the fetus. Additionally, the incomplete choices (E, F, G) do not align with the recommended vaccinations during pregnancy.
A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
- A. Blood glucose 58 mg/dL
- B. Hematocrit 48%
- C. Platelets 100,000/mm³
- D. Hemoglobin 16 g/dL
Correct Answer: C
Rationale: The correct answer is C: Platelets 100,000/mm³. This finding should be reported as it indicates a low platelet count, which can lead to bleeding issues in the newborn. A normal platelet count in a newborn is typically higher than 150,000/mm³. Low platelets can increase the risk of bleeding, especially in the setting of birth trauma.
A: Blood glucose 58 mg/dL is within the normal range for a newborn.
B: Hematocrit 48% is within the normal range for a newborn.
D: Hemoglobin 16 g/dL is within the normal range for a newborn.
In summary, the correct answer is C because it signifies a potential health concern for the newborn, while the other options fall within normal ranges and do not require immediate medical attention.